<html>
    <head>
        <meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1" />
        <title>insurance</title>    
        <link href="validate.css" rel="stylesheet" type="text/css" />     
        <script src="insurance.js"></script>
    </head>
    <%@page import="java.sql.ResultSet"%>
<%@page import="java.sql.Statement"%>
<%@page import="sai.mysql.DriverLoading"%>
    <body>
    <center>
        <form name="iregister" id="iregister" method="get" onsubmit="return check(this)" action="./insurance">
            <table border="0">
                <%!
                String pid;
                %>
                <%                
                pid = request.getParameter("uid");               
                %>
                <tr>
                    <td>Patient Id:</td>
                    <td><input type="text" name="patientid" id="patientid" readonly="readonly" value="<%=pid%>" /></td>
                    <td><div id="id1">please enter valid patient id</div></td>
                </tr>
                <tr>
                    <td>Insurance Provider:</td>
                    <td><select name="iname" id="iname">
                            <option value="--select--">--select--</option>
                            <option value="star health">star health</option>
                            <option value="lic">lic</option>
                            <option value="appolo">appolo</option>
                            <option value="hdfc">hdfc</option>
                        </select></td>
                </tr>
                <tr>
                    <td>Branch:</td>
                    <td><select name="branch" id="branch">
                            <option value="--select--">--select--</option>
                            <option value="Kukatpally">kukatpally</option>
                            <option value="Secudearabad">Secudearabad</option>
                            <option value="Tarnaka">Tarnaka</option>
                            <option value="Koti">Koti</option>
                        </select></td>
                </tr>
                 <tr>
                    <td>Address:</td>
                    <td><textarea rows=5 cols=15 name="address" id="address" ></textarea></td>
                </tr>
                <tr>
                    <td>Contact No. of office:</td>
                    <td><input type="text" name="ocontact" id="ocontact" /></td>
                </tr>
                <tr>
                    <td>Agent Name:</td>
                    <td><input type="text" name="aname" id="aname" /></td>
                </tr>
                <tr>
                    <td>Contact No. of Agent:</td>
                    <td><input type="text" name="acontact" id="acontact" /></td>
                </tr>
                <tr>
                    <td><input type="submit" name="Register" value="Register" /></td>
                </tr>
            </table>
        </form>
    </center>
</body>
</html>
